City
Request for Replacement Refund Check
Instructions: Please indicate your name, current mailing address, and daytime telephone
number in Box 1. Provide the name(s) as shown on the list of outstanding checks. Sign
and date the certification and return it to the Tax Office by mail at the below address, or
by fax at 713-368-2249. Please call 713-274-8100 with any questions.
Ann Harris Bennett
Harris County Tax Assessor-Collector
P.O. Box 4520
Houston, Texas 77210-4520
Box 1
Information regarding person or company requesting a replacement refund check
NAME:
ADDRESS:
City:
State:
Zipcode:
Telephone:
Box 2
Number
Name(s) as shown on the
outstanding list
Check
Number
Taxpayer Account
Number/Vehicle
Identification Number
Amount
New Check
Number
Certification
By signing below, I hereby certify that I am the person named above and that I am entitled
to the replacement refund check requested. The information I have given on this form is
true and correct. I understand that any person who makes a false entry upon this record
shall be subject to penalties of perjury.
Signature of Applicant Date
AC-502 Rev. 08/20
